Malnourishment & MMR lessons

TOI ,Crest ( 24/10/09)Welfare Inc
Multinational corporations are lining up products fortified with micronutrients to help fight malnourishment in rural India, but health experts warn against business interests swamping welfare work
REMA NAGARAJAN TIMES INSIGHT GROUP

Conventional wisdom would suggest that malnourished, poverty-stricken people living on less than $2 a day can hardly be of interest to the market. But conventional wisdom could be wrong. Giant multinational food companies are developing products meant to specifically tackle the fallout of prolonged hunger, such as micronutrient deficiency and anaemia. Think of any big name in food and you can bet it’s there in the throng reaching out to the starving billions.
But why would Coca-Cola, Pepsi, Hindustan Unilever Ltd (HUL), Britannia and Danone be keen to sell beverage and food products containing micronutrients like vitamin A, zinc and iron at rockbottom prices?
The answer lies in the numbers. Over a billion hungry people globally, and more than two billion anaemic. India alone boasts the world’s largest undernourished population — over 200 million. To the food industry, these figures would mean the mantra of ‘low margin, high volume sales’ of fortified products is viable. As a bonus, the company would also be building brand value by undertaking the responsibility of helping those in distress.
Tying up with NGOs provides the entry point to create impact on the minds of rural India. For instance, Coca-Cola is marketing Vitingo, a micronutrient fortified orange-flavoured beverage, in partnership with Laxmi Priya Enterprises, a sister concern of Bharat Integrated Social Welfare Agency (BISWA), a leading NGO micro-finance institution in Orissa, with a beneficiary base of over 5,00,000. The pilot project entails Vitingo sachets being distributed using self-help groups. Coca-Cola says the effort is aimed at building a sustainable, not-forprofit business “wherein we would market beverages enriched with micronutrients targeted at the bottom of the socio economic pyramid”.
Coke seems upbeat about its prospects after the success of a pilot in Sambalpur district of Orissa. Considering micronutrient deficiencies can impair cognitive development, lower resistance to disease in children and adults, and increase risks for both mothers and infants during childbirth, Coke would expect the new initiative to generate both goodwill and sales.
For most corporates, such rural initiatives are also a learning process, which helps them understand new markets that are extremely price sensitive or culture specific. Pepsi, too, is looking at the NGO route to push a drink to be launched next year, which it claims can reduce the incidence of anaemia among women in rural India. It is hoping to distribute the drink through local health centres.
The poor themselves might not be able to afford even these products despite the low pricing, but the companies have an eye on humanitarian agencies and government-run health programmes to market them. Bagging a government contract could mean immediate sales running into millions.
In recent years, the Global Alliance for Improved Nutrition (GAIN), a private sector coalition, has been using its ties with UNICEF to persuade governments to allow more food fortification. The GAIN Business Alliance, chaired by Unilever, also helps conduct surveys to help member companies assess feeding practices and gauge the market for complementary and supplementary food. “Unilever has been working in partnership with GAIN since 2005, and has been very actively involved in food fortification programmes of GAIN in various countries, including India. As well as its strongly-principled stance, Unilever has a vested interest in the health, education and success of consumers in all our markets,” says a Unilever spokesperson.
But public health experts insist that such concerted efforts to combat malnutrition are only driven by business interests and lobbies rather than any serious attempt at addressing poverty, hunger and poor health. A paper published this month in the journal Lancet, titled ‘Nutrition in Early Life-Global Priority’, warns that the limited funding for combating undernutrition is being dominated by programmes for food aid and micronutrient supplementation. “Although such programmes have a definite role in some circumstances, one would also like to see strong investments in community-based approaches — like the promotion of breastfeeding and appropriate complementary foods — which have well-established effects on child survival and nutritional status,” says the paper.
Dr B Sasikeran, director of the National Institute of Nutrition, Hyderabad, says, “Obviously, they are not interested in the public good. They are commercial entities after all.” Whenever the institute has done clinical trials to determine the efficacy of micronutrient supplementation, the children’s group in the trial that was not given the supplement showed almost as much improvement as the group getting the supplement. Dr Sesikeran explains why this happens: “During a trial, you monitor both groups closely, ensuring they get the same kind of balanced diet, that the children undergo regular deworming and so on. With balanced food and good healthcare, even those without the supplements are bound to do well.” Dr Sesikeran adds that this only proved that public health/nutrition schemes could show substantial results even without supplements if only they were monitored and implemented properly.
Essentially, the case made by experts is for the need to build efficient public or community-based distribution mechanisms that can deliver commodities like oil, fresh vegetables and milk to supplement staple foods. “When we talk of food, we talk of rice and wheat, which only takes care of hunger. Once we take care of hunger, we have to talk of more oil and green vegetables in the diet to take care of micronutrient deficiency,” says Umesh Kapil, professor of Public Nutrition at the All India Institute of Medical Sciences.
Nutritionists also point out that if there is no food in the stomach to provide the base, nutrients are of little use and hence supplements alone would not work for the hungry. But international agencies looking for ways to tackle undernourishment in large sections of the population are often accused of encouraging quick-fix solutions through promotion of fortified foods. Dr Neeraj Sethi, senior advisor (health), Planning Commission, pointed out at a conference on micronutrient deficiencies that emphasis is shifting to fortification and supplementation, ignoring the importance of sustainable child feeding practices like exclusive breastfeeding till six months, safe drinking water and sanitation, and deworming of children at regular intervals.
The arguments are yet to be resolved, but clearly the issue is one that will loom over the fate of future generations. After all, the largest section of the world’s undernourished population is in India and most of them are young children.
(With additional inputs
from Rupali Mukherjee and
Namrata Singh)

THE UNDERBELLY OF THE MARKET

Corporate majors are selling a range of fortified products at competitive prices or distributing them free of cost
COCA-COLA launched Vitingo, a micronutrient fortified orange-flavoured beverage in Orissa this year, jointly with an NGO micro-finance institution
PEPSI is expected to launch an ultra-cheap soft drink that could cost just Rs 1 or 2 per serve at the beginning of next year. The drink, it is said, will reduce incidence of anaemia among women in rural India
HINDUSTAN UNILEVER has launched Brooke Bond Sehatmand in Madhya Pradesh and Bihar, a tea brand expected to fulfill vitamin needs in the lower strata of society. It claims three cups of the tea guarantee delivery of 50 per cent of the recommended dietary allowance of added B Vitamins required by a person
DANONE launched Shaktidoi, sweet curd fortified with iron and vitamins, in 2006 in partnership with Grameen in Bangladesh, selling it at five to seven taka per pot
BRITANNIA started working with an NGO to distribute fortified biscuits — Tiger with Iron-Zor — free of cost to children living in slums in Haryana. Its projects are primarily aimed at tackling iron deficiency in towns and rural areas. The iron-fortified biscuits are also sold elsewhere in the country
ECONOCOM FOODS sells Epap, a pre-cooked maize-based food, highly fortified with 28 nutrients, developed to address Africa’s food and nutrition problem

OUTLOOK ( 2/11/09)Women: Maternal Mortality-Expecting Hope
Bangladesh offers India a healthcare lesson by Amba Batra Bakshi
Lifestart

* The maternal mortality rate (MMR) in India is 254 per 1 lakh live births (2004-2006), down from 301 in 2001-2003
* India has set itself an MMR target of 109 by 2015, which Unicef says the country will not be able to achieve
* India wants to see how Bangladesh brought down MMR
* Indian health officials will travel to Bangladesh to study that country’s intervention models
Despite efforts by the government to arrest the alarming maternal mortality rate (MMR) in India, progress has been very slow in the past few years. Outlook has now learnt the government is considering taking a leaf out of Bangladesh’s efforts at containing maternal mortality. India’s MMR is currently 254 per one lakh live births; the target is to take that figure to 109 by 2015. Unicef’s ‘The State of the World’s Children’ report released this year estimated that “78,000 women die from pregnancy and childbirth” every year in India and that the country was unlikely to achieve the 2015 target.

Amit Mohan Prasad, joint secretary in the Union ministry of health & family welfare, says, “The latest figures have shown that our MMR, which was 301 in 2001-03, has come down to 254 in the 2004-06 period. This is largely due to the success of Janani Suraksha Yojna (JSY), which is being seen as a success internationally.” The JSY, which falls under the umbrella of the National Rural Health Mission (NHRM), covers all pregnant women belonging to households below the poverty line and above 19 years of age for up to two live births. JSY integrates ante-natal care, institutional delivery with cash incentives and post-delivery care. “We are open to learning and exchanging ideas,” says Prasad. “Many countries want to adapt some of our intervention methods and we don’t mind studying theirs.”

In Bangladesh, the Australian Aid Programme in 2008-09 achieved positive results in decreasing maternal mortality rates in a pilot project. A 13 per cent decrease in MMR was achieved, from 254 per one lakh live births in 2007 to 221 in 2008 (compared to the national rate of 320). This is seen as a giant leap in checking MMR in Bangladesh. Indian health ministry officials will be travelling to Dhaka to study Bangladesh’s initiative in detail to implement them back at home. “Bangladesh has had very intensified efforts in the areas that record high MMR. Results only come from the betterment of the overall medical system. And since their health system is weaker than ours, we want to study the few things that caused this positive outcome and hopefully implement it,” says a health official.

In India, efforts have focused on increasing the number of institutional deliveries in rural areas, spreading awareness on contraception and family planning and mobilising more skilled health workers. But it’s the cash incentives to delivering a baby in a hospital that have brought more women to hospitals. Prasad insists that since the project only started in 2005, the full results will only show in the next assessment. However, he did not want to comment on the chances of India failing to achieve its 2015 target.

For India, another struggle is against the huge gaps in the healthcare system from state to state. Two-thirds of all the maternal deaths in the country occur in Uttar Pradesh, Uttarakhand, Bihar, Jharkand, Orissa, Madhya Pradesh, Chhattisgarh, Rajasthan and Assam. In these states, the administration of schemes has largely failed. Nepal, on the other hand, has made a giant leap, bringing down MMR from 540 to 280. This is being seen as a result of the legalisation of abortion in 2002. Also, Sri Lanka has the lowest MMR in South Asia at just 27 in 2002. A well-connected maternal healthcare system and a large number of institutional deliveries have led to these results. India could take a few tips from these countries too.